Provider Demographics
NPI:1841803590
Name:JOHNSON, MELODY (CCSH)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CCSH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:GA
Mailing Address - Zip Code:30179-3708
Mailing Address - Country:US
Mailing Address - Phone:678-988-0705
Mailing Address - Fax:
Practice Address - Street 1:100 PROFESSIONAL PL STE 307
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3872
Practice Address - Country:US
Practice Address - Phone:770-812-5977
Practice Address - Fax:770-812-5981
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA263246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty